Vasectomy

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

PURPOSE

The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.

MATERIALS AND METHODS

We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.

RESULTS

Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.

CONCLUSIONS

Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

Paternity seven years after a negative post-vasectomy semen analysis: a case report

BACKGROUND

Vasectomy is one of the permanent methods of contraception; however, the risk of conception still exists. Early failure, defined as a postoperative semen analysis showing persistent motile sperm, occurs in 1 in every 250 patients. Late failure, defined as the rejoining of the severed ends of the vas deferens, occurs in 1 in every 2000 patients.

CASE PRESENTATION

A healthy 37-year-old British male presented to our clinic because his wife had conceived seven years after he had undergone a vasectomy. The result of his semen analysis after the vasectomy was negative, and the histopathological report confirmed that the sample contained tissue from both the left and right vas deferens. His wife conceived seven years after the procedure, and semen analysis at that time confirmed a total of 0.5 million sperm per milliliter of semen in a total semen sample of 6.3 ml. The total number of motile sperm recorded was 2.5 million.

CONCLUSION

This case shows that late recanalization can occur up to seven years after a vasectomy. Patients should be informed prior to the procedure that late recanalization, although rare, may still occur. Post-vasectomy paternity necessitates further counseling to ensure that the patient and the patient's partner fully understand the implications and options available to them.

Expression and function of HSP110 family in mouse testis after vasectomy

HSP110 functions to protect cells, tissues, and organs from noxious conditions. Vasectomy induces apoptosis in the testis; however, little is known about the reason leading to this outcome. The aim of the present study was to evaluate the expression and function of HSP110 in mouse testis after vasectomy. Following bilateral vasectomy, we used fluorescent Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) to detect apoptosis, Western blotting and immunohistochemistry to examine HSP110 expression and localization. Serum antisperm antibody (AsAb) and testosterone were measured by Enzyme-linked immunosorbent assay (ELISA) and radioimmunoassay, respectively. Expression of endoplasmic reticulum stress (ERS) sensors and downstream signaling components was measured by Reverse Transcription-Polymerase Chain Reaction (RT-PCR), and the phosphorylation of eIF2α and JNK was detected by Western blotting. Vasectomy induced morphologic changes, increased apoptosis in the testis, increased serum AsAb, and decreased testosterone levels. After vasectomy, ORP150 mRNA level was increased first and then decreased, Bcl-2 was decreased, and the expression of HSPA4l, GRP78, GADD153, PERK, ATF6, IRE-1, XBP-1s, Bax, Bak, and caspases and the phosphorylation of eIF2α and JNK were increased. We present that an ER stress-mediated pathway is activated and involved in apoptosis in the testis after vasectomy. HSPA4l and ORP150 may play important roles in maintaining the normal structure and function of testis.

Loupe-Assisted Vasovasostomy Using a Prolene Stent: A Simpler Vasectomy Reversal Technique

Purpose

Microsurgical vasovasostomy is associated with high patency and pregnancy rates, but is difficult and requires significant effort and time to learn. Therefore, we assessed a simplified loupe-assisted vasovasostomy method using a Prolene stent.

Materials and Methods

The medical records of 82 patients who underwent loupe-assisted vasovasostomy with a Prolene stent by a single surgeon between January 2004 and December 2015 were reviewed. The association between the vasal obstructive interval (VOI) and the success rate was evaluated.

Results

The average age at the time of vasovasostomy was 39.8 years (range, 29~57 years). The mean VOI was 6.6 years (range, 1~19 years). The mean operation time was 87.0 minutes (range, 55.0~140.0 minutes). The overall patency and natural pregnancy rates were 90.2% and 45.1%, respectively. The success rate decreased as time after vasectomy increased (odds ratio, 0.869; 95% confidence interval, 0.760~0.993; p=0.039). The cases were divided into 2 groups according to the mean VOI: group A (>7 years) and group B (≤7 years), with 31 cases (37.8%) and 51 cases (62.2%), respectively. The patency and pregnancy rates of group A were 80.6% and 51.6%, respectively, while those of group B were 96.1% and 41.2%, respectively.

Conclusions

Loupe-assisted vasovasostomy using a Prolene stent is a safe and effective method.

The effect of vasectomy on the sexual life of couples

INTRODUCTION

There are several contraceptive methods to prevent pregnancy, reversible as well as nonreversible ones. The sexual satisfaction of couples is affected by many types of contraceptives used.

AIM

The aim of this study was to evaluate prospectively the effect of vasectomy on the sexual life and satisfaction of couples.

METHODS

Seventy-six couples took part in this evaluation and filled out respective questionnaires before and after vasectomy. All the questionnaires were evaluated statistically for differences in the respective sexual domain scores.

MAIN OUTCOME MEASURES

Standardized questionnaires were used. The International Index of Erectile Function (IIEF) as well as postoperative pain score were completed by men. Female Sexual Function Index (FSFI) was completed by the female partner. For statistical analysis, the T-Square Test was used.

RESULTS

The average age of couples, who chose the vasectomy procedure, was 37 years for women and 39 years for men. The contraception method most frequently used prior to the vasectomy was the birth control pill. For the male partner, the IIEF showed no significant change in the respective domains. Out of the 76 couples, 93% of the males and 96% of their female partners would recommend and do vasectomy again. The postoperative pain score was 3.5 on 0-10 scale, and there were no postoperative complications reported. The best improvement of the sexual function was noticed for the female partners. The FSFI showed a significant improvement in the domains desire (P < 0.05), arousal (P < 0.05), orgasm (P < 0.05), lubrication (P < 0.05), and satisfaction (P < 0.05).

CONCLUSION

This is the first report to our very best knowledge that showed the positive impact of vasectomy on sexual satisfaction of couples. Vasectomy is a safe operation with minimal complication rates.

The significance of sperm heads and tails within the vasal fluid during vasectomy reversal

INTRODUCTION

The finding of only sperm heads and/or short tails (SHST) during vasectomy reversal (VR) creates a difficult decision for the best method of vasal reconstruction, i.e. vasovasostomy (VV) or epididymovasostomy (EV). Using outcome analyses, we report the impact of SHST alone and combined with qualitative analysis of gross fluid quality in predicting successful VR.

MATERIALS AND METHODS

The records of 356 men who underwent VR by a single surgeon from 2005 to 2012 were retrospectively reviewed. Intravasal fluid was assessed for gross quality (i.e., clear, opaque, pasty or creamy) as well as microscopic composition (i.e., motile or non-motile whole sperm, SHST or no sperm). The post-operative patency rates and semen analysis parameters were assessed.

RESULTS

Fourteen men (3.9%) demonstrated SHST bilaterally in the vasal fluid. The median duration from vasectomy was 6.0 years (interquartile range 4.0-9.8). Bilateral VVs were performed on 12 men (86%), while two men (14%) had a unilateral VV and a contralateral EV. Of the 26 vasa undergoing VR, the majority of the fluid quality was classified as creamy (n = 20 vasa, 76.9%). The remaining fluid was classified as pasty (n = 3 vasa, 11.5%), opaque (n = 2 vasa, 7.7%) and clear (n = 1 vasa, 3.8%). In cases undergoing bilateral VV with only SHST, patency rates were 90.9%, and both cases of unilateral EV were patent (100%).

CONCLUSIONS

VV was successful in 90.9% of patients undergoing VR in the setting of SHST alone. Even when creamy or pasty fluid was present, the results surpassed the expected patency rate for an EV. Therefore, the presence of only SHST, regardless of fluid quality, should not dissuade the surgeon from performing a VV.

CONCLUSIONS

VV was successful in 90.9% of patients undergoing VR in the setting of SHST alone. Even when creamy or pasty fluid was present, the results surpassed the expected patency rate for an EV. Therefore, the presence of only SHST, regardless of fluid quality, should not dissuade the surgeon from performing a VV.

Compliance with semen analysis

PURPOSE

We calculated the compliance rate and determined which population of men would be more or less likely to be compliant with semen analysis followup based on demographic information and complication rates.

MATERIALS AND METHODS

We retrospectively reviewed the records of 946 consecutive patients who underwent vasectomy at an ambulatory clinic, as performed by 1 urologist. Standard followup consisted of a telephone call or prebooked appointment 2 months after vasectomy and 2 semen analyses 4 months after vasectomy.

RESULTS

Average ± SD patient age was 33.6 ± 5.4 years. Of the 946 study patients 47.9% did not submit a negative semen sample, 15.7% submitted 1 and 36.4% submitted the required 2 negative samples to confirm successful vasectomy according to the sampling protocol. Mean time to semen analysis was 4.53 ± 2.14 months. Complications included infection in 1.9% of cases, hematoma in 1% and sperm granuloma in 0.5%. Men 34 years or younger, men with 3 or more children and men without complications were more likely to be noncompliant with semen analysis.

CONCLUSIONS

The number of men who provided samples for semen analysis in this study was low, although they were given written and verbal reminders. This poor patient compliance is similar to that in previous studies. We identified a subset of patients with poor compliance, which may allow urologists to target preprocedure counseling more appropriately.

Vasectomy Influences Expression of HE1 but not HE2 and HE5 Genes in Human Epididymis

Epididymal roles include protection and transport, maturation, and storage of the sperm cells. It is known that these functions are altered under vasectomy, but the consequences of excurrent duct obstruction on the pattern of gene expression along the human epididymis are poorly documented. In order to understand how excurrent duct occlusion affects different epididymal regions, the expression pattern of genes known to be expressed in specific epididymal segments was investigated along the epididymides of vasectomized men. Selected human epididymal complementary DNAs (cDNAs) identified by differential library screening were studied because of their unique messenger RNA (mRNA) distribution along the different epididymal segments. In situ hybridization as well as immunohistologic studies were undertaken to investigate the effect of vasectomy on a gene expressed all along the epididymis (HE1) or more selectively in the proximal (HE2) or distal (HE5) segment. The HE1 transcript was affected by the obstruction of the epididymis with little or no mRNA detectable along the epididymis. The HE1-related antigen was shown by immunohistochemical methods to be reduced within the epithelium of the epididymis of vasectomized men. By contrast, HE5 mRNA and protein, expressed in epithelial cells of the distal epididymis, were not affected by the obstruction of the vas deferens. Similarly, HE2 transcriptional and translational products normally expressed in the caput epididymidis were not affected by vasectomy. These results show that excurrent duct obstruction differentially affects the expression pattern of some specific transcripts and their encoded proteins, probably impairing their fundamental roles in the physiology of the epididymis.

Preoperative factors influencing postoperative results after vasovasostomy

PURPOSE

The purpose of this study is to evaluate the preoperative factors that influenced postoperative sperm concentration after vasovasostomy.

MATERIALS AND METHODS

We retrospectively reviewed 97 consecutive single-layer vasovasostomy procedures performed by a single surgeon between March 2003 and September 2010. The patients were stratified into three groups based on sperm concentration at 1 month follow-up: group I-azoospermia, group II-oligospermia, and group III-normal. We evaluated the preoperative factors that may have influenced sperm concentration at postoperative 1 month. Patients with serial semen analysis were divided into four groups according to the change in postoperative sperm concentration at the 6-month visit: group II-N-from oligospermia to normal, group II-O-from oligospermia to oligospermia, group III-O-from normal to oligospermia, group III-N-from normal to normal. We compared the pregnancy rate among the four groups.

RESULTS

The mean obstructive interval was 9.69 years in group I, 6.02 years in group II, and 7.82 years in group III. There were significant differences found among the groups (p=0.035). There was significantly different change in sperm concentration, sperm motility, and sperm morphology between each of the groups. A total of 32 patients underwent serial semen analyses at 1 month, 3 months, and 6 months after vasovasostomy. There was no significant difference in patient age, obstructive interval, or follicle-stimulating hormone among the groups. The natural pregnancy rate in group II-O was lower than that in group II-N, and in group III-O was lower than that in group III-N. However, there was no significant difference among each of the groups.

CONCLUSIONS

The sperm concentration after vasovasostomy was significantly related to the obstructive interval between vasectomy and reversal.

Morphological alterations and distribution of occludin in rat testes after bilateral vasectomy

The aim of study was to investigate the fate and the morphology of the cells which constitute the spermatogenic line, and to determine the distribution of occludin in the testis in adult vasectomized Wistar rats. The rats were divided into two groups: control group (sham-operated) and vasectomized group. One, 3 and 6 months after sham and vasectomy operations, testis samples were examined. The weight of the testes was found to be reduced 3 and 6 months after vasectomy. There was vacuolization in the seminiferous tubules one month after vasectomy. The tubules showed severe atrophy 3 and 6 months after vasectomy. The occludin immunolabeling in the 3- and 6-month groups was weak and diffuse, and the density of the protein was found to be decreased. The increase in the number of apoptotic cells was accompanied by a time-dependent decrease in the number of haploid, diploid and tetraploid cells. This study demonstrated that vasectomy causes degeneration in the seminiferous tubules with alterations in occludin distribution with a decrease in the number of spermatogenic cells. Moreover, these alterations increase in a time-dependent manner.

Prognostic value of intraoperative parameters observed during vasectomy reversal for predicting postoperative vas patency and fertility

INTRODUCTION

During vasectomy reversal, it is common practice to examine the intravasal fluid both grossly and microscopically and comment on the presence or absence of a sperm granuloma, but the prognostic value of these findings is debated in the literature. Our aim is to determine the value of intraoperative semen consistency and quality as well as the presence of a sperm granuloma on predicting vas patency and fertility following vasectomy reversal.

MATERIALS AND METHODS

A retrospective review of 351 patients who underwent vasectomy reversal by a single surgeon was performed. Intraoperative semen consistency and the presence of a sperm granuloma were assessed macroscopically. A modified Silber score was applied after microscopic evaluation of vas fluid. Semen consistency, semen quality and the presence of a sperm granuloma were correlated with postoperative vas patency and pregnancy.

RESULTS

In our patient collective, the vas patency rate was 93.3% resulting in a pregnancy rate of 62.4%. The data support a trend for clear and opalescent semen consistency towards higher postoperative rates of vas patency (P=0.062) and fertility (P=0.057). Silber score correlated with fertility (P=0.018) but not vas patency (P=0.148). The presence of a sperm granuloma was associated with vas patency (P=0.029), but not with fertility (P=0.881).

CONCLUSION

We demonstrate that in patients undergoing vasectomy reversal a lower Silber score predicts higher rates of postoperative fertility. At the same time, the presence of a sperm granuloma is associated with postoperative vas patency. This information can guide intraoperative decision-making in both the anastomotic technique implemented and additional interventions performed intraoperatively to allow for higher fertility following vasectomy reversal.

Effect of obesity on sex hormone levels, antisperm antibodies, and fertility after vasectomy reversal

OBJECTIVES

Little is known about the effect of obesity as quantified by the body mass index on the serum levels of sex hormones, antisperm antibodies, and postoperative fertility of men undergoing vasectomy reversal. The aim of the present study was to investigate the effect of obesity on sex hormone levels, the presence of antisperm antibodies, and fertility after vasectomy reversal.

METHODS

We identified 500 patients with complete clinical and laboratory data who had undergone vasectomy reversal by a single surgeon. Data on postoperative vas patency and pregnancy were available for 315 and 334 patients, respectively.

RESULTS

Postoperative vas patency was observed in 93.2%, 91.9%, and 93.3% of normal weight, overweight, and obese patients, respectively (P = .931). Pregnancy was achieved by the partners of 63.9%, 60.2%, and 55.6% of the normal weight, overweight, and obese patients, respectively (P = .672). An increased body mass index was associated with lower serum testosterone levels (P < .001). Significant associations were found between both patient age (P = .007) the and presence of IgA antisperm antibodies (P = .006) with the body mass index. In the logistic regression analyses, the age of the female partner was the only independent predictor of postoperative pregnancy (P = .039).

CONCLUSIONS

Our results have highlighted that no specific testing before vasectomy reversal can aid in predicting the fertility outcome and that patients should be counseled that the age of their female partner will have an effect on their likelihood of conceiving after vasectomy reversal. In overweight and obese patients, the clinical signs of hypogonadism should be examined and the serum testosterone level should be investigated.

Clearance after vasectomy: has the time come to modify the current practice?

OBJECTIVE

Vasectomy is a simple, reliable and effective form of permanent contraception. Clearance after vasectomy has been the subject of much debate among urologists. Poor compliance with postvasectomy semen analysis is well recognized, with rates as low as 36%. This can leave the partner at risk of an unplanned pregnancy and, consequently, the surgeon at risk of litigation. Although there is no consensus about the requirements for postvasectomy clearance, urologists usually tend to request at least two azoospermic postvasectomy semen samples (PVSSs) before labelling patients as sterile. This study investigated whether simplifying the criteria for postvasectomy clearance can result in improved compliance.

MATERIAL AND METHODS

Medline, Embase and Cochrane databases were searched for studies on postvasectomy clearance. The main focus of the search was on the timing and number of PVSSs, their impact on patients' compliance and the significance of the rare non-motile sperm (RNMS).

RESULTS

It has been found that patients' compliance decreases when more than one PVSS is requested. One azoospermic PVSS can be as indicative of sterility as two azoospermic samples. There have been calls for a uniform protocol recommending only one routine sperm sample taken 16 weeks postoperatively. This period will allow the vasa and seminal vesicles to become clear of spermatozoa. A significant proportion of men will have RNMS in their semen after vasectomy; only 1% will ultimately fail. Therefore, RNMS samples can, for practical purposes, be considered azoospermic and one PVSS, even if containing RNMS, should be considered sufficient for clearance.

CONCLUSIONS

Provided that patients are adequately warned about the risk of vasectomy failure and appropriate consent is obtained, a single azoospermic PVSS at 16 weeks is sufficient for clearance. Patients with RNMS should be practically considered azoospermic and further sampling should be abandoned. This approach should improve patients' compliance. Evaluation in a prospective setting will be required to validate this conclusion.

A novel modification of no-scalpel vasectomy: a preliminary report

OBJECTIVE

To present a novel technique of no-scalpel vasectomy (NSV) that has the potential to decrease the failure rate.

PATIENTS AND METHODS

From 2006 until 2008 vasectomy was performed by ligating head-to-head and tail-to-tail the cut ends of the vasa deferentia. The outcome of the procedure was assessed by three semen analyses, the first two of which were carried out three months postoperatively and the third one at the end of the study period. SPSS version 13 was used to analyse data.

RESULTS

Fifty-four patients participated in this study. The operating time amounted to an average of 16 minutes. The mean duration of follow-up was 17.7 +/- 6.69 months (range: 12-34). The outcome of the procedure overall was excellent with a minimum of complications.

CONCLUSION

Vasal head-to-head and tail-to-tail ligation in NSV shows promise as a safe and effective sterilisation procedure.

Impact of obstructive interval and sperm granuloma on patency and pregnancy after vasectomy reversal

The objective of this study was to determine the effect of the obstructive interval and the presence of a sperm granuloma on vas patency and pregnancy rate following vasectomy reversal. We identified 334 patients with complete follow-up who met the inclusion criteria. There were significant associations between the obstructive interval and procedure performed as well as with patient age. Patients with longer obstructive intervals were more often older (p < 0.001) and more likely to have a vaseoepididymostomy performed (p < 0.001). There was no association between the presence of a sperm granuloma or the length of the obstructive interval with post-operative vas patency and pregnancy rates. The only independent predictor of post-operative fertility was age of the female partner (p = 0.015). Our data clearly demonstrates that when state of the art surgical techniques are used, neither the presence of a sperm granuloma nor the obstructive interval serve as prognosticators of post-operative vas patency and pregnancy rates. However, when counselling patients and their female partners, it is of utmost importance to stress that the age of the female partner is an independent predictor of successful vasectomy reversal.

Fulguration of the lumen does not improve vasectomy sterilization rates

OBJECTIVES

To assess the effect of adding lumen diathermy fulguration to our standard technique of vas ligation with polyglactin 910 (Vicryl(TM), Ethicon, Sommerville, NJ, USA) excision and fascial interposition, in an attempt to improve our sterilization rates. We previously reported the effect of changing suture material on vasectomy success rates; 3005 post-vasectomy semen analyses (PVSA) revealed a decrease in sterilization rates after surgery on changing from chromic catgut to polyglactin 910.

PATIENTS AND METHODS

We retrospectively reviewed PVSA undertaken for vasectomies performed by urological surgeons at the Mid-Yorkshire NHS Trust for 18 months from September 2005 to February 2007.

RESULTS

There were 592 vasectomies in all; the age distribution of patients between the groups treated with the standard and new method was similar. Overall, 166 patients (28%) failed to provide two semen samples as instructed, and so were excluded from further analyses. Sterility was achieved in 367 patients (86%); a further 28 (7%) have indeterminate analyses to date, with one of the last two PVSAs showing sperm, with the PVSA of 32 (7%) patients showing persisting sperm. For the eight surgeons reviewed the sterility rates were broadly similar.

CONCLUSIONS

The introduction of diathermy fulguration of the lumen has not improved vasectomy sterilization rates, with up to 14% having sperm on PVSA.

Persistent Motile Sperm After Ligation Band Vasectomy

PURPOSE

We evaluated the efficacy and mechanism of failure in a small case series of VasClip vasectomies.

MATERIALS AND METHODS

Between September 2003 and March 2004, 8 patients underwent elective vasectomy using the VasClip ligation band. Microscopic semen analysis was done a minimum of 4 weeks postoperatively and after at least 15 ejaculations. The number of sperm and motility were quantified in 15 or more high power fields. Successful vasectomy was defined as 2 consecutive postoperative unspun semen analyses containing no sperm. Patients with failed vasectomy underwent bilateral surgical removal of the vas deferens segments containing the ligation band for gross and histological analysis.

RESULTS

Six of 8 patients (75%) were deemed azoospermic after 2 semen analyses at a mean followup of 7 and 11 weeks postoperatively, respectively. Two of 8 patients (25%) had semen analyses containing multiple motile sperm after vasectomy. In the 2 failed cases 1 side was patent, as demonstrated by vasal cannulation and irrigation with dilute methylene blue despite a well positioned, intact and secure ligation band. Histological analysis showed extravasation and sperm granuloma on the patent side.

CONCLUSIONS

The VasClip was found to fail at an unexpectedly high rate. Pathological analysis suggests sperm extravasation and fistula tract formation as the mechanism. One failure resulted in an unwanted pregnancy, which demonstrates the need for patient counseling regarding postoperative followup.

Clinical and Pathological Findings in Testis, Epididymis, Deferens Duct and Prostate following Vasectomy in a Dog

We report the case of a bilateral and multilocular spermatocele and sperm granuloma in a dog that was vasectomized 5 years before. Clinical examination revealed scrotal dermatitis and benign prostatic hyperplasia. Orchiectomy was performed, and gross and histological examination showed testicular degeneration associated with epididymal sperm granuloma. In relation to this case, the literature about long-term effects of vasectomy in dogs has been reviewed. On the basis of these results, a preventive sonogram and physical assessment in prostate and other reproductive structures before vasectomy is recommended.

Assessment of sexual function in patients undergoing vasectomy using the international index of erectile function

INTRODUCTION

The present study aims to prospectively compare the sexual function in males before and after vasectomy surgery using the international index of erectile function (IIEF).

MATERIALS AND METHODS

From October to December 2002, sixty-four patients who were candidates for male sterilization in the vasectomy program of the Urology Section at the General Hospital of the University of São Paulo were included. The same investigator applied the IIEF before and 90 days after the surgery. The mean scores obtained on pre and postoperative visits for all domains of sexual function were analyzed and compared with the Wilcoxon test.

RESULTS

The mean patient age was 35 years (range from 25 to 48 years) and the mean number of children per man was 3. The total mean score of the IIEF was 64.06 before surgery and 65.64 after the procedure, with this difference considered statistically significant (p < 0.001). Sixty-seven per cent of the patients improved their scores, versus 17% and 16% who showed worsening or no change at all in IIEF scores following surgery, respectively. Of the 5 sexual function domains, desire and sexual satisfaction presented statistically significant improvement.

CONCLUSION

This study showed that vasectomy caused a positive impact on sexual function, especially on desire and sexual satisfaction, in the majority of men undergoing surgery. There was no case of surgery-related erectile dysfunction.

HOW LITTLE IS ENOUGH? THE EVIDENCE FOR POST-VASECTOMY TESTING

PURPOSE

Post-vasectomy semen analysis (PVSA) is the traditional method of confirming sterility after vasectomy. However, PVSA protocols vary in the end points accepted, and the number and timing of tests. In this systematic review we make evidence based recommendations on the appropriate PVSA protocol.

MATERIALS AND METHODS

Databases (MEDLINE, Current Contents, Cochrane Library and EMBASE) were searched up to and including March 2003. Studies were included if they dealt with post-vasectomy testing and contained data on at least 1 of the time or number of ejaculations to azoospermia, pregnancy, repeat vasectomy and histological analysis of vas specimens.

RESULTS

A total of 56 studies were included in the review. Time to achieve azoospermia was variable, although the median incidence of patients with azoospermia was consistently more than 80% after 3 months and after 20 ejaculations. A small percent of patients (14,845 or 1.4%) demonstrated persistent nonmotile sperm, although some of them eventually achieved azoospermia. The reappearance of nonmotile sperm was reported in 7 studies, occurring up to 22 months after vasectomy.

CONCLUSIONS

The evidence supports a PVSA protocol with 1 test showing azoospermia after 3 months and 20 ejaculations. If the sample is positive, periodic testing can continue until azoospermia is achieved. Patients with persistent nonmotile sperm in low numbers could be given cautious assurance of success. No evidence was located to support histological testing of the excised vas deferens.

Preclinical evaluation for noninvasive reversal following long-term vas occlusion with styrene maleic anhydride in langur monkeys

A preclinical evaluation for reversal through a noninvasive approach following long-term vas occlusion with styrene maleic anhydride (SMA) has been attempted in langur monkeys at the level of semen parameters, sperm functional tests, semen biochemistry, histology and ultrastructure of reproductive organs, hematology and serum clinical biochemistry including antisperm antibodies (ASA), prostate-specific antigen (PSA) and testosterone. Noninvasive reversal through palpation, percutaneous squeezing and electrical stimulation, forced vibratory movements and suprapubic percussion in the inguinal segments and per-rectal digital massage was attempted in seven langur monkeys after 540 days following vas occlusion. The results revealed instant azoospermia reversal on the same day of reversal with impaired sperm quality, which showed gradual improvement and normospermia with normal motility and viability after 60-90 days of reversal. Sperm functional tests, including ultrastructure of spermatozoa, indicative of sterility in the initial ejaculations, reached normalcy after 90-120 days of reversal. The seminal plasma biochemistry indicative of obstructive azoospermia regained a normal pattern after 90-120 days of reversal. The morphology of testes that showed focal degeneration during 540 days of vas occlusion and that of vasa deferentia that showed exfoliation of epithelial cells resumed to normal morphology comparable with control animals after 150 days of reversal. The morphology of the epididymis, seminal vesicle and prostate did not show appreciable changes following vas occlusion and after noninvasive reversal compared with those of control animals. Hematology, serum clinical chemistry, ASA, PSA and testosterone fluctuated within control limits, indicating safety of the procedure at the level of accessory reproductive organs. The results suggest that noninvasive reversal is feasible even after long-term vas occlusion with SMA and is safe without adverse side effects.

Vasectomy-dependent dysregulation of a local renin-angiotensin system in the epididymis of the cynomolgus monkey (Macaca fascicularis)

The mammalian epididymis is a fundamental organ for sperm cell maturation; it allows mammals to acquire their fertilizing ability. We have previously shown that during obstruction in cases of vasectomy, gene expression profiles were modified in human and cynomolgus monkey epididymides. Paracrine factors thus appear to be key elements in local gene expression along the epididymis. Local renin-angiotensin systems (RAS) have been described in many other organs as paracrine regulators of gene expression. This work demonstrates the presence of a local RAS in the epididymis of the cynomolgus monkey and investigates the vasectomy-dependent changes occurring in this system. After unilateral vasectomy in 4 monkeys (two for 3 days and two others for 7 days), the presence of two major components of the RAS (ie, angiotensinogen [ANG] and the type 1 receptor to angiotensin II [AT-I]) was evaluated in the vasectomized and the normal controlateral epididymides of each monkey. We also show by in situ hybridization that the principal cells of the epididymis express ANG and AT-I mRNAs and immunohistochemistry permitted to verify the co-localization of the AT-I protein and mRNA. Quantitative comparisons of individual variations in the mRNA and protein profiles for ANG and AT-I revealed that vasectomy altered the RAS expression profiles in an individual manner, thus confirming its role as a local system. This study provides a good basis for further investigation of the possible implications of the RAS in the physiology of the epididymis. Furthermore, the individual dependent modifications are in accordance with the very fluctuating results obtained in the fertility status of human patients undergoing a vasectomy reversal. The variations observed in the RAS expression profiles may be a good model to study the causes of the overall epididymal gene expression dysregulation that follows vasectomy and potentially affects fertility.

Vasectomy follow-up: Clinical significance of rare nonmotile sperm in postoperative semen analysis

OBJECTIVES

To examine patient compliance, complications, and significance of rare nonmotile sperm (RNMS) after no-scalpel vasectomy.

METHODS

We reviewed the records of 690 consecutive men who had undergone vasectomy at our institution between 1996 and 2002. All men were instructed to submit two initial semen samples for analysis (3 and 4 months after vasectomy) and additional samples (at 2-month intervals) if sperm were identified on the initial and subsequent analyses. All patient complaints (telephone and clinic visit) were recorded.

RESULTS

A total of 315 men (45.6%) did not submit any semen samples. Of the 295 men who submitted two samples, 176 (60%) were azoospermic, 110 (37%) had RNMS, and 9 men (3%) had rare motile sperm (the vasectomy of 1 of these 9 men subsequently failed). Of the 110 men with RNMS, 83 submitted one or more additional semen samples. Of these 83 men, 62 (75%) had become azoospermic, 20 (24%) had persistent RNMS, and 1 (1%) subsequently had a failed vasectomy (with motile sperm). The 2 patients with failure underwent a repeat vasectomy (failure rate 0.67% [2 of 295]). A total of 69 patients (10%) reported a complaint, but only 9 (1.5%) of these men returned for clinical examination. No surgical complications and no pregnancies occurred.

CONCLUSIONS

Our data show that despite aggressive counseling, compliance with follow-up testing is very poor. Patient-reported complaints are common but minor. We found that most men with RNMS become azoospermic and propose that the presence of RNMS is consistent with a successful vasectomy. However, long-term, prospective studies are needed to assess the risk of late failure in men with RNMS.

[Vasectomy: study of 300 interventions. Review of the national literature and of its complications]

OBJECTIVES

The aims of this paper are: 1. To study the demand and reasons why of the vasectomy in area 12 of Valencian Community. 2. To analyse the adverse effects of our series and the predictable risk factors. 3. To review the adverse effects in the national series. 4. To review the adverse effects referred to in international publications.

PATIENTS AND METHODS

A retrospective study was made of 300 patients who had submitted themselves to a vasectomy between january 1992 and december 2000. All the clinical dossiers were reviewed according to 10 pre-established variables. age, number of offspring, reasons why, pre-vasectomy anticontraceptives; date of operation, type of anaesthesia used, pathologic anatomy, semen analysis after vasectomy, adverse effects and their possible causes (risk factors). The basic statistic study was done using a data base of Microsoft Access and the interpretations of the different variables using a table of Excel.

RESULTS

The demand for contraceptive attention (vasectomy) is the 8th cause for external urological consulting and the 4th for urological local ambulatory surgery of our area. 300 operations were done during that period. The average age of the patients was 37.5 years old (ranging from 25 to 51). The number of offspring ranged from 1 to 7, with a promedia of 2.41 children/patient. The reasons why were: voluntary family planning (86%), medical illnesses of the female which contraindicated gestation (9%), genetic reasons (4.33%) and social-sanitary problems (0.66%). Contraceptive methods used by 71.63% are known: The widest-used method being IUD (49.74%) and the preservative (25.88%). 30 patients (10%) had adverse effects, 29 patients having light adverse effects. The most frequent were: 12 orchiepididymitis (4%), 5 spermatic granulomas (1.66%), 3 chronic scrotal pain (1%), 2 scrotal haematoma (0.66%) and 2 bleeding (0.66%). There was one serious complications and of all the cases mentioned above only one needed hospitalization (impetigo-sepsis) and another needed surgery due to a spermatic granuloma. There were no pregnancies or post-vasectomy court cases. 81% of the patients had been declared azoospermic within 45 to 60 days after the vasectomy in one or two consecutive semen analysis.

CONCLUSIONS

The vasectomy is a safe and simple way for male sterilization. It's the most widely done urologic operation in Spain. The technique isn't extent of adverse effects (0 to 18%) and its seriousness varies from a simple ecchymosis to Fournier's gangrene, endocarditis or sepsis. A doctor would be considered negligent if he/she didn't inform the patient about the remote possibility of a spontaneous recanalisation of the vas deferens leading to renewed fertility (failure of the vasectomy). It is imperative to give post-vasectomy information where the patient must continue using his habitual anticonceptive method until the azoospermia shown in 2 semen analysis confirm the sterility of the patient so that the urologist has no legal problem.

Stereological analysis of the human testis after vasectomy indicates impairment of spermatogenic efficiency with increasing obstructive interval

OBJECTIVE

To quantify germ cell loss and the extent of testicular fibrosis in vasectomized patients of varying obstructive intervals.

DESIGN

Retrospective study.

SETTING

Specialized male reproductive surgery and endocrinology service.

PATIENT(S)

Thirty-four vasectomized patients 1-20 years after surgery and 10 normal subjects.

INTERVENTION(S)

Thirty-four testicular biopsies taken at the time of vasectomy reversal (vasovasostomy). Control biopsies taken from 10 normal men at the time of vasectomy.

MAIN OUTCOME MEASURE(S)

Stereological assessment of testicular germ cell populations and testicular fibrosis.

RESULT(S)

Vasectomy caused a significant decrease in germ cells in the later stages of spermatogenesis, with significant reductions in pachytene spermatocytes (by 18%), round spermatids (by 40%), elongating spermatids (by 23%), and elongated spermatids (by 39%). The loss of spermatids showed a significant relationship with obstructive interval. A significant 2.7-fold increase in total (peritubular plus interstitial) fibrosis was observed, which showed a positive relationship with obstructive interval. Decreased germ cell populations and fibrosis did not seem to be related to sperm antibody levels nor to sperm counts obtained up to 2 years after vasovasostomy.

CONCLUSION(S)

Vasal obstruction results in significant reductions in germ cells in the later stages of spermatogenesis and increases in testicular fibrosis, both worsening with an increasing obstructive interval. Testicular damage after vasectomy might impact upon the prospects for reversal.

[Ambulatory vasectomy. Risks and complications]

Vasectomy is the simplest and most effective method of permanent sterilization in men. In most cases, the surgical technique includes conventional vasoresection with incision of the scrotal skin or no-scalpel vasectomy as a minimally invasive method. The most important complications following surgery are haemorrhage and haematoma (1.2%), infection (3.5%), epididymitis/epididymo-orchitis (2.1%), sperm granuloma (2-70%), and chronic pain (3-8%). No long-term negative organic effects have been proven in clinical studies. The surgeon's experience and the technique applied are essential for the postoperative course, whereas performing vasectomy either on an in-patient or out-patient basis does not seem to have an influence. To evaluate the success of the vasectomy, follow-up spermiograms are obligatory. If immotile spermatozoa are present further follow-ups are necessary. Vasectomy needs to be reperformed if motile spermatozoa are detected. The chance of an unsuccessful vasectomy is below 1%. Unprotected intercourse must not be performed before two consecutive spermiograms show azoospermia.

[Vasectomy today: a review of 1,275 vasectomies in 10 years]

We report on a large series of 1,275 patients who underwent outpatient vasectomy performed by a single urological surgeon within a 10-year period. In addition, the results of a prospective questionnaire-based study on 217 patients regarding their opinions and motivation, and the financial aspects of the vasectomy are discussed. The mean age was 37.0+/-5.9 years. A total of 98.4% of the patients had an uneventful postoperative course. The average duration of sick leave was 2.2+/-0.21 days. During the study period, the length of sick leave dropped significantly from 2.63 (1990/91) to 1.1 days (1998/99; P=0.001). Efficacy was documented with azoospermia rates of 96.6% and 98.5% in patients who presented for two and three sperm examinations, respectively. A vast majority of patients (94.6%) felt that the procedure should be covered by their health insurance, although 88.1% stated they would also pay by themselves. A minority of patients (0.7%: 9/1,275) subsequently considered vasectomy reversal. The wish to reverse the vasectomy was significantly associated with a younger patient age. In conclusion, outpatient vasectomy provides a safe and reliable form of contraception at low cost. Overall satisfaction in appropriately counselled patients is very high. Based on these findings, further attempts to propagate vasectomy as a timely form of contraception are medically and socioeconomically recommended.

Vasovasostomy

Vasovasostomy after sterilisation vasectomy is the most frequently performed microsurgical intervention in refertilizing surgery. Causes for obstruction other than vasectomy such as juvenile hernia repair and other kinds of surgery affecting the seminal cord appear to be rare. The pre-operative diagnostic approach follows the rules of conventional diagnostics in male infertility. The significance of the intra-operative evaluation of aspirates from the duct and its role in surgical decision-making is controversely debated in the literature. Similar controversies are evident concerning the microsurgical technique that is applied. In particular, the advantages of the two-layered technique (gold standard) of the anastomosis versus the single-layered technique are discussed. Other techniques such as laser applications and fibrin glue are not routinely used in humans. Even difficult microsurgical problems in cases with extended obstructions and cases of re-vasovasostomy can nowadays be managed and have significant success rates. Important prognostic factors appear to be the interval of obstruction, sperm granulomas, and length of the testicular end of the duct. High success rates accompanied by a lower profile in cost make the microsurgical approach (refertilization) superior versus the primary use of ART techniques such as ICSI.

Effect of vasectomy on gene expression in the epididymis of cynomolgus monkey

Vasectomy has been shown to affect the pattern of mRNA expression of P34H, a human sperm protein added to the acrosomal cap during epididymal transit. It has been reported that vasectomy alters the histology of the reproductive tract in various species as a result of the increased pressure in the epididymis. The aim of this study was to evaluate if other epididymis-specific mRNAs, which are expressed in different patterns along the duct, are altered by vasectomy as well. We analyzed the expression of P31m (a monkey homologue of human P34H) and three different HE-like (HE-l) mRNAs along the epididymis in the cynomolgus monkey (Macaca fascicularis). Sexually mature cynomolgus monkeys were vasectomized unilaterally; then the epididymides were surgically removed at different time points. The ipsilateral normal epididymis was used as a control. Histomorphometric measurements showed that the height of the epididymal epithelial cells started to be affected only at 14 wk postsurgery. However, Northern blot and in situ hybridization analysis showed that the expression pattern of P31m, HE1, and HE5-like mRNA along the epididymis was not affected by vasectomy. Only the HE2-like mRNA predominantly expressed in the normal corpus epididymidis was significantly lowered 14 wk after vasectomy. Thus, ductal obstruction differentially alters mRNA expression along the epididymis of the cynomolgus monkey.

Relationship between time period after vasectomy and the reproductive capacity of sperm obtained by epididymal aspiration

BACKGROUND

It is not well defined whether the elapsed time after vasectomy has any influence on the outcome of IVF-ICSI using epididymal sperm. We analysed retrospectively the results of 151 ICSI cycles in which sperm of vasectomized men were used at different time periods after vasectomy.

METHODS

Oocytes were obtained after a desensitizing ovarian stimulation protocol using GnRH agonist in association with recombinant FSH and HCG. Sperm were retrieved by percutaneous epididymal sperm aspiration. The cycles were split into three groups: < or =10 years after vasectomy (group 1, n = 47), 11-19 years after vasectomy (group 2, n = 79), and > or =20 years after vasectomy (group 3, n = 25).

RESULTS

As might be expected, the mean age of men differed in the three groups (group 3 > group 2 > group 1), and the mean age of the women was also significantly higher in group 3 than in groups 1 and 2, although no differences were described between groups 2 and 3. All other laboratory and clinical parameters were similar in the three groups. Ongoing pregnancy and implantation rates (34, 25, 8% and 22, 15, 6% respectively) decreased significantly from group 1 to group 3.

CONCLUSION

Pregnancy and implantation rates after ICSI with sperm from vasectomized men are negatively correlated with the time interval from vasectomy, which cannot be explained purely by male or female ageing.